Nursing leadership and the quality of care

Anne Margreet van Dishoeck, PhD

Susanne Maassen, RN, MSc

Margo van Mol, RN, MSc

The blind spot of quality indicators in nursing care

Anne-Margreet van Dishoeck

prof. Johan P. Mackenbach en

prof. Ewout W. Steyerberg

Historical perspective

Florence Nightingale

“It may seem a strange principle to enunciate as the very first

requirement in a hospital that it should do the sick no harm”

Chapter Hospital statistics, 1863 Notes on Hospitals

Her dream on hospital statistics;

“enabling us to ascertain the mortality in different hospitals, as well as

from different diseases and in different districts of the same country and

improve the treatment and management of the sick and maimed poor”

.

Avedis Donabedian

Hospital performance; Quality and Safety

Transparency and accountability of delivered care using performance

indicators

Performance indicators as a basis for

public accountability

external assessment

supervision and purchase

supporting patient choice

internal management control

quality improvement

Issues associated with performance measure

Definition of the concepts

Quality of the data

Gaming

Influence of confounding factors in comparing hospitals

random variation

case mix

Quality improvement

Aim of this research

Evaluating the use of outcome and process indicators in comparing

hospitals and in improving the quality of hospital care

Project and Methods

Rankability

1. Hospital comparison

Random variation, outcome indicators Dutch Inspectorate

Graphical displays random variation

Rankability

Variation within the hospital

Variation between the hospitals

Case mix, data on surgical site infections

2. Process outcome relation

Pressure ulcers and quality of prevention; audit case control study

3. Actionability; Improving quality

Door-to-needle time in Stroke patients; interrupted time series analysis

Improving pressure ulcer prevention; interrupted time series design

Random variation

• lack of differences in

outcome

• small numbers in patiënt

population

• rare outcome

van Dishoeck, A. M., Looman, C. W., van der Wilden-van Lier, E. C., Mackenbach, J. P.,

Steyerberg, E. W. (2011). BMJ Qual Saf, 20(8), 651-657.

Case mix

van Dishoeck, A. M., Koek, M. B., Steyerberg, E. W., van Benthem, B. H., Vos,

M. C., & Lingsma, H. F. (2013).. Br J Surg, 100(5), 628-636;

Observed

differences

between hospitals

Random

variation

Adjusted differences

between hospitals

Case mix

Adjusted differences

between hospitals

Definition and

registration

differences

Unmeasured

case mix

variables

Quality of care

van Dishoeck, A. M.,

Lingsma, H. F., Mackenbach,

J. P., & Steyerberg, E. W.

(2011). BMJ Qual Saf, 20(10),

869-874

Comparing hospital performance without indication of

uncertainty and without correction for patient factors is

impossible

Summarizing comparing hospitals

Process-outcome relation

Pressure Ulcer prevalence; a case control study

Assessment of the care process with 9 criteria

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

contr

case

contr

case

contr

case

contr

case

contr

case

contr

case

contr

case

contr

case

contr

case

risk

assessment

patient

information

repositioning heel

prevention

alternating

mattressess

incontinence

profylaxe

adequate

nutrition

skin

assessment

non-

recommended

interventions

major

shortcoming

minor

shortcoming

no

shortcoming

Quality score

0 No suboptimal factors have been identified

1 One or more suboptimal factors have been identified, but is unlikely to

have failed to prevent pressure ulcer of this patient

2 One or more suboptimal factors have been identified, and possibly

have failed to prevent pressure ulcer of this patient

3 One or more suboptimal factors have been identified, and is likely to

have failed to prevent pressure ulcer of this patient

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

cases controls

quality score

suboptimal care 3

suboptimal care 2

suboptimal care 1

optimal care

Conditional logistic regression analysis

PU- Pressure Ulcer

Univariable Multivariable

Variables OR CI p-value OR CI p-value

Quality score 2.0 1.3-3.1 0.001 1.9 1.1-3.3 0.032

PU risk score 1.3 1.2-1.5 <0.001 1.3 1.1-1.5 0.018

Illness type (benign/malign) 3.3 1.2-9.3 0.014 4.3 0.9-20.1 0.067

Care needs before admission 2.6 1.2-5.6 0.014 2.3 0.7-7.1 0.15

Number of care problems 1.6 1.2-2.1 0.003 1.2 0.8-1.8 0.34

Age per decade 1.6 1.2-2.0 0.001 1.2 0.8-1.7 0.51

IC admission during stay 3.9 1.4-11 0.011 1.4 0.3-6.7 0.71

van Dishoeck, A. M., Looman, C. W., Steyerberg, E. W., Halfens, R.

J., & Mackenbach, J. P. (2016). J Adv Nurs.

Improving quality

Acute care in stroke patients; door-to needle time

Database

Erasmus Stroke

Registry

van Dishoeck, A. M., Dippel, D. W., Dirks, M.,

Looman, C. M., Mackenbach, J. P., & Steyerberg,

E. (2014). Cerebrovascular Diseases Extra(4), 149-

155

Improving Quality of Care

Segmented regression analysis of an interrupted time series

Pressure ulcer prevention; outcome indicator

Data Erasmus

MC University

Medical Centre

5,1%

13,5%

11,1%

3,0%

0,0%

2,9%

12,5%

15,2%

nosocomial pressure ulcers cat. 2-4, incl inc. derm.

i

n

t

e

r

v

e

n

t

i

o

n

Improving Quality of Care

Pressure ulcer prevention; process indicator

Data Erasmus MC

University Medical

Centre

65,1%

46,2%

18,4%

91,7%

94,4%

54,3%

84,2%

97,1%

% risk assessment

Conclusion; For internal quality improvement, process indicators

seem to be more informative than outcome indicators. van Dishoeck, A. M., Steyerberg, E., van Lanschot, J.

J. B., Hovius, S. E. R., & Mackenbach, J. P. (2016). to

be submitted.

Conclusion

We must be aware that a performance indicator may offer an uncertain

signal on quality and is by no means an absolute measure

Nursing leadership; Measuring what Matters

Wong, C. A., Cummings, G. G., & Ducharme, L. (2013). The relationship between

nursing leadership and patient outcomes: a systematic review update. J Nurs

Manag, 21(5), 709-724.

SM Maassen RN MSc, MMC van Mol RN MSc,

CM Dekker-van Doorn PhD.

The professional nursing work environment: the

experience of Dutch nurses in a university

hospital

Care to elderly

Complex care

situations

Poly farmacie

Multi morbidity

Clinical reasoning

Integrated care

Value based

health care

Professional nurses

Professionale nurses in professional

workenvironment

„A setting that support excellence and decent work. In

particular, they strive to ensure the health, safety and

personal wellbeing of staff, support quality patient care and

improve the motivation, productivity and

performance of individuals and organisations’ (ICN, 2008).

Professional work environment: local situation

+/- 2200 nurses

270.000 nursing days

9 thema’s, 6 with nurses

Foundation nursing

council, development

professional practice

model

Aim

To explore the nurses´ perception of their professional nursing

work environment.

Method

Cross sectional survey

1 hospital

PES-NWI

Dutch translation

Results

Descriptives

Results

ANOVA

Discussion

Dutch-PES: reliability

Interventions?

Implications

Practice

Discussion about staff & resources

Learning from eachother

Gaining more influence on content of practice

Interventions

Research

Link to quality outcomes?

Longitudinal study

THE INFLUENCE OF EMPATHIC ABILITY AND AUTONOMY ON SUSTAINING WORK ENGAGEMENT AMONG INTENSIVE CARE NURSES

Margo van Mol

Psychologist and ICU nurse

06-10-2016

Department of Intensive Care , Erasmus MC University Medical Center, Rotterdam

The Netherlands Institute for Health Sciences (NIHES), Rotterdam

Frail elderly in the intensive care unit (ICU)

More than half of the current ICU population is aged 65 or above, using 60% of total ICU days

Complications of elderly ICU patients

• More comorbidity

• Higher rates of delirium

• Higher mortality rate

• Higher expenditure of healthcare costs

Bagshw et al., (2016) Critical Care 20:175 Riou and Boddaert, (2015) Critical Care Med:231-232 Nicoll et al., (2003) JAGS 51:591-593

Morally decision making

Work-related stress

increasingly complex and emotionally

demanding

a damaging effect on individual´s job

satisfaction

results in long-term absenteeism

subsequent hospital understaffing

Work-related stress in nurses

Moss M, et al., (2016) CHEST Journal 150(1):17-26

Working as a nurse

Work-related stress might reduce the quality of care for patients and relatives and threaten patient safety

Work engagement, a counterbalance to work-related stress

The aim of this study is to explore the association between personal resources and work engagement among the ICU professionals.

Work engagement

• Defined as:

• Vigour

• Dedication

• Absorption (flow)

Schaufeli WB, et al., (2002) Journal of Happiness studies 3(1):71-92 Schaufeli, W.B. and A.B. Bakker, (2004) Journal of organizational Behavior 25(3):293-315

Benefits high level of work engagement

• Positive effect on own health

• Good balance of work-life

• Low absenteeism

• High team spirit

• Safe work environment (patients and professionals)

• High quality of care

• Improve patient satisfaction

• Organizational involvement

• Inspiring work environment • Development of personal leadership

Engaged daily practice of caring to frailty elderly

Job-Demands-Resources Model 1,2

1. Bakker AB, (2011) Current Directions in Psychological Science 20(4):265-269.

2. Schaufeli WB, Taris TW, (2014) Springer:43-68.

Balanced model with positive and negative aspects of work :

- Motivational process - Stress process

Personal leadership

• Cognitive

• Emotional

• Perspective taking

Empathic ability

• Resilience

• Autonomy

Personal resources

Cross-sectional study design

• Inclusion:

• All ICU nurses and ICU nurse students (N= 262), all intensivist (N=53)

• More than 12 hours/week working in an ICU in Erasmus MC

• Method

• Composed questionnaire with Utrecht Work Engagement Scale and the Jefferson Scale of Physician Empathy

• Announcement and introduction by management team

• Anonymity guaranteed

• Personal invitation with digital link to the questionnaire

• Weekly response per unit in the newsletter

• Reminder at non-response, max 3x

• Individual report with feedback of results

Respondents

• Response rate 61%

• Characteristics of respondents

Age Gender A-level

54% 34 hr/wk 68% 32%

Working hours

Unit Eligible N %

ICV-1 46 29 63%

ICV-2 81 41 51%

ICV-3 81 44 54%

ICCU 54 43 80%

Intensivists 53 32 60%

Total 315 193 61.3%

Job demands

Work load too high 3.1% (NL 3.6%)

Emotional demand Physical demand Cognitive demand

Satisfaction with work (% satisfied/very satisfied)

Work engagement

Weekly working hours remained as a confounding factor on work engagement

Vigor Absorption Dedication Distance

Overall the same results in job resources (social support, communication, team efficacy, team spirit) compared to the benchmark

Personal resources

Emotional empathy Cognitive empathy

Compared to health care professionals

Autonomy Resilience

Personal leadership will shape the role of nursing and may increase sustaining work engagement.

Conclusion

• The physical and emotional workload in the ICU may have been high, but the personal resources seemed to suffice for the respondents • “Business as usual”

• ICU professionals respect the patients and relatives, they can imagine the situation, but remain at a certain emotional distance • This might be a protective reaction for their own emotional health

• Nurses should present personal leadership in the complex care to frail elderly and their relatives, however this is “work in progress”

Questions?